{"id":10270,"date":"2024-03-05T15:33:23","date_gmt":"2024-03-05T20:33:23","guid":{"rendered":"https:\/\/dev.lasik.com\/formulario-de-contacto-de-cogestion\/"},"modified":"2024-10-22T15:33:00","modified_gmt":"2024-10-22T19:33:00","slug":"formulario-de-contacto-de-cogestion","status":"publish","type":"page","link":"https:\/\/www.lasik.com\/es\/formulario-de-contacto-de-cogestion\/","title":{"rendered":"Inscripci\u00f3n \/ Opt-in de Cogesti\u00f3n"},"content":{"rendered":"\n<h3 class=\"wp-block-heading has-text-align-center\">\u00bfTe interesa asociarte con LASIK.com?<\/h3>\n\n<h3 class=\"wp-block-heading has-text-align-center\">\u00bfNecesitas actualizar la informaci\u00f3n de tu consulta?  <\/h3>\n\n<h3 class=\"wp-block-heading has-text-align-center\">Rellene nuestro formulario de contacto y nos pondremos en contacto con usted lo antes posible.<\/h3>\n\n<div class=\"wp-block-group has-shade-background-color has-background has-global-padding is-layout-constrained wp-container-core-group-is-layout-3b379e29 wp-block-group-is-layout-constrained\" style=\"padding-top:var(--wp--preset--spacing--32);padding-right:var(--wp--preset--spacing--32);padding-bottom:var(--wp--preset--spacing--32);padding-left:var(--wp--preset--spacing--32)\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_9' style='display:none'><style>#gform_wrapper_9[data-form-index=\"0\"].gform-theme,[data-parent-form=\"9_0\"]{--gf-color-primary: 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<\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/es\/wp-json\/wp\/v2\/pages\/10270' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_31\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_31'>Have You Co-Managed With a LASIK Provider Before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_9_31' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_9_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_26'>Were you a member of the LASIKPartners Program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_9_26' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unsure' >Unsure<\/option><\/select><\/div><\/div><div id=\"field_9_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Who Have You Co-Managed With Before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_9_28' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='LasikPlus' >LasikPlus<\/option><option value='TLC Laser Vision' >TLC Laser Vision<\/option><option value='The LASIK Vision Institute' >The LASIK Vision Institute<\/option><option value='Whiting Clinic' >Whiting Clinic<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_9_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_30'>Other Brand<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_9_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Doctor Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_1'>\n                            <span id='input_9_1_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_1.2' id='input_9_1_2'    aria-required='false'   >\n                          <option value=''>Dr.<\/option><option value='Dr.' >Dr.<\/option><option value='Miss' >Miss<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Mx.' >Mx.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_9_1_2' class='gform-field-label gform-field-label--type-sub '>Prefijo<\/label>\n                                                  <\/span>\n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_4'>Doctor Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_9_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_4\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_9_4'>This MUST be a Unique Email to you specifically. Our CRM does not allow us to have more than one contact with the same email address.<\/div><\/div><div id=\"field_9_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_5'>Doctor Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_9_5' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_7'>Practice Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_11'>Practice Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_9_11' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_9_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_8'>Practice Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_9_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_9'>Practice Fax<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_9_9' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Practice Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_9_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_9_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_10_1' id='input_9_10_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_9_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_10_2' id='input_9_10_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_9_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_10_3' id='input_9_10_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_10_4_container' >\n                                        <select name='input_10.4' id='input_9_10_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_9_10_4' id='input_9_10_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_9_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_10_5' id='input_9_10_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_9_10_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_9_32\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_32'>Geographic Market (City)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_9_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Albany' >Albany<\/option><option value='Albuquerque' >Albuquerque<\/option><option value='Atlanta' >Atlanta<\/option><option value='Austin' >Austin<\/option><option value='Baltimore' >Baltimore<\/option><option value='Billings' >Billings<\/option><option value='Birmingham' >Birmingham<\/option><option value='Boise' >Boise<\/option><option value='Boston' >Boston<\/option><option value='Charleston' >Charleston<\/option><option value='Charlotte' >Charlotte<\/option><option value='Charlottesville' >Charlottesville<\/option><option value='Chicago' >Chicago<\/option><option value='Cincinnati' >Cincinnati<\/option><option value='Cleveland' >Cleveland<\/option><option value='Columbus' >Columbus<\/option><option value='Dallas-Ft. Worth' >Dallas-Ft. Worth<\/option><option value='Dayton' >Dayton<\/option><option value='Denver' >Denver<\/option><option value='Des Moines' >Des Moines<\/option><option value='Detroit' >Detroit<\/option><option value='El Paso' >El Paso<\/option><option value='Fairfield' >Fairfield<\/option><option value='Fargo' >Fargo<\/option><option value='Ft. Lauderdale' >Ft. Lauderdale<\/option><option value='Grand Rapids' >Grand Rapids<\/option><option value='Greenville' >Greenville<\/option><option value='Hartford' >Hartford<\/option><option value='Houston' >Houston<\/option><option value='Indianapolis' >Indianapolis<\/option><option value='Jacksonville' >Jacksonville<\/option><option value='Kansas City' >Kansas City<\/option><option value='Las Vegas' >Las Vegas<\/option><option value='Lexington' >Lexington<\/option><option value='Little Rock' >Little Rock<\/option><option value='Louisville' >Louisville<\/option><option value='Madison' >Madison<\/option><option value='Memphis' >Memphis<\/option><option value='Miami' >Miami<\/option><option value='Milwaukee' >Milwaukee<\/option><option value='Minneapolis' >Minneapolis<\/option><option value='New York City' >New York City<\/option><option value='New Orleans' >New Orleans<\/option><option value='Oklahoma City' >Oklahoma City<\/option><option value='Omaha' >Omaha<\/option><option value='Orlando' >Orlando<\/option><option value='Out of Market' >Out of Market<\/option><option value='Paramus' >Paramus<\/option><option value='Philadelphia' >Philadelphia<\/option><option value='Out of Market (Other)' >Out of Market (Other)<\/option><option value='Paramus' >Paramus<\/option><option value='Philadelphia' >Philadelphia<\/option><option value='Phoenix' >Phoenix<\/option><option value='Pittsburgh' >Pittsburgh<\/option><option value='Portland' >Portland<\/option><option value='Providence' >Providence<\/option><option value='Raleigh-Durham' >Raleigh-Durham<\/option><option value='Richmond' >Richmond<\/option><option value='Salt Lake City' >Salt Lake City<\/option><option value='San Antonio' >San Antonio<\/option><option value='Seattle' >Seattle<\/option><option value='Spokane' >Spokane<\/option><option value='St. Louis' >St. Louis<\/option><option value='Syracuse' >Syracuse<\/option><option value='Tampa' >Tampa<\/option><option value='Tucson' >Tucson<\/option><option value='Tulsa' >Tulsa<\/option><option value='Virginia Beach' >Virginia Beach<\/option><option value='Washington DC' >Washington DC<\/option><option value='West Palm Beach' >West Palm Beach<\/option><option value='White Plains' >White Plains<\/option><\/select><\/div><\/div><fieldset id=\"field_9_12\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Practice Primary Contact Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_12'>\n                            \n                            <span id='input_9_12_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.3' id='input_9_12_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_12_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_12_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.6' id='input_9_12_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_12_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_13\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_13'>Practice Primary Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_9_13' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_9_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_14'>Practice Tax ID #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_9_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_24\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_24'>W9 Form (PLEASE SUBMIT IF WE DO NOT HAVE ON FILE)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='67108864' \/><input name='input_24' id='input_9_24' type='file' class='large' aria-describedby=\"gfield_upload_rules_9_24\" onchange='javascript:gformValidateFileSize( this, 67108864 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_24'>Tipos de archivos aceptados: jpg, gif, png, pdf, Tama\u00f1o m\u00e1ximo de archivo: 64 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_9_24'><\/div> <\/div><\/div><fieldset id=\"field_9_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are You Associated With<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_15'>\n\t\t\t<div class='gchoice gchoice_9_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No (Other)'  id='choice_9_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_0' id='label_9_15_0' class='gform-field-label gform-field-label--type-inline'>No (Other)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='SNAPP'  id='choice_9_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_1' id='label_9_15_1' class='gform-field-label gform-field-label--type-inline'>SNAPP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='ALLDOCS'  id='choice_9_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_2' id='label_9_15_2' class='gform-field-label gform-field-label--type-inline'>ALLDOCS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Vision Source'  id='choice_9_15_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_3' id='label_9_15_3' class='gform-field-label gform-field-label--type-inline'>Vision Source<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='AEG'  id='choice_9_15_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_4' id='label_9_15_4' class='gform-field-label gform-field-label--type-inline'>AEG<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='MyEyeDr'  id='choice_9_15_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_5' id='label_9_15_5' class='gform-field-label gform-field-label--type-inline'>MyEyeDr<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Target Optical'  id='choice_9_15_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_6' id='label_9_15_6' class='gform-field-label gform-field-label--type-inline'>Target Optical<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='LensCrafters'  id='choice_9_15_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_7' id='label_9_15_7' class='gform-field-label gform-field-label--type-inline'>LensCrafters<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Visionworks'  id='choice_9_15_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_8' id='label_9_15_8' class='gform-field-label gform-field-label--type-inline'>Visionworks<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Co-Management Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_9_19'><div class='gchoice gchoice_9_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Pre-Op Only'  id='choice_9_19_1'   aria-describedby=\"gfield_description_9_19\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_1' id='label_9_19_1' class='gform-field-label gform-field-label--type-inline'>Pre-Op Only<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Pre and Post Op'  id='choice_9_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_2' id='label_9_19_2' class='gform-field-label gform-field-label--type-inline'>Pre and Post Op<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Referral Only'  id='choice_9_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_3' id='label_9_19_3' class='gform-field-label gform-field-label--type-inline'>Referral Only<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_19_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Seleccionar todos\" data-label-deselect=\"Deseleccionar todos\">Seleccionar todos<\/button><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_19'>What co-management options are you interested in? <\/div><\/fieldset><div id=\"field_9_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_22'>How Did You Hear About This Program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_9_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Email' >Email<\/option><option value='Friend\/Family' >Friend\/Family<\/option><option value='Search Results (Google\/Bing)' >Search Results (Google\/Bing)<\/option><option value='LinkedIn' >LinkedIn<\/option><option value='LASIKPartners' >LASIKPartners<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_9_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_23'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_9_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button 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